ANTIHYPERLIPIDEMIADarmawan,dr.,M.Kes,Sp.PD

Plasma lipids consist mostly of lipoproteinsSpherical complexes of lipids and specific proteins (apolipoproteins).

The clinically important lipoproteins, listed in decreasing order of atherogenicity:LDLLery–low- density lipoprotein (VLDL)ChylomicronsHDL

LIPOPROTEIN METABOLISM

Exogenous/chylomicron pathway (dietary fat)

Endogenous pathway (lipids synthesized by the liver)

HDL metabolism (apolipoprotein transfer, cholesteryl ester transfer, reverse cholesterol transport)

Reduction of LDL-C is the primary goal of cholesterol-lowering therapy.

Treatment options for hypercholesterolemia:Lifestyle changes, such as diet, exercise, and weight reduction Treatment with HMG CoA reductase inhibitors (statins) is the primary treatment option for hypercholesterolemia.

Treatment options for hypertriglyceridemia Diet and exercise are the primary mode treatment

If indicated:Niacin and fibric acid derivatives; are the most efficacious in lowering triglyceridesOmega-3 fatty acids (fish oil) in adequate doses may also be beneficial

Antihyperlipidemic drugs

• statins

• niacin, fibrates

• bile acid– binding resins, a cholesterol absorption inhibitor

• omega-3 fatty acids

may be used alone or in combination

should always be accompanied by lifestyle modifications, such as exercise and a diet low in saturated fats.

HMG CoA reductase inhibitors

3-Hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (commonly known as statins) lower elevated LDL-C

Resulting in a substantial reduction in coronary events and death from CHD. Therapeutic benefits:

plaque stabilization,

improvement of coronary endothelial function

inhibition of platelet thrombus formation

antiinflammatory activity

The HMG CoA reductase inhibitors also decrease triglyceride levels and may increase HDL cholesterol levels in some patients.

STATINS

Therapeutic uses: These drugs are effective in lowering plasma cholesterol levels in all types of hyperlipidemias. However, patients who are homozygous for familial hypercholesterolemia lack LDL receptors and, therefore, benefit much less from treatment with these drugs.

Pharmacokinetics: Lovastatin and simvastatin are lactones that are hydrolyzed to the active drug. The remaining statins are all administered in their active form. Absorption of the statins is variable (30% to 85%) following oral administration. All statins are metabolized in the liver, with some metabolites retaining activity. Excretion takes place principally through bile and feces, but some urinary elimination also occurs

STATINS

Adverse effects

STATINS

Adverse effects

Elevated liver enzymes may occur with statin therapy.

[Note: Hepatic insufficiency can cause drug accumulation.]

Myopathy and rhabdomyolysis (disintegration of skeletal muscle; rare) have been reported: In most of these cases, patients usually had renal insufficiency

Plasma creatine kinase levels should be determined in patients with muscle complaints

The HMG CoA reductase inhibitors may also increase the effect of warfarin

NIACIN (NICOTINIC ACID)

Niacin can reduce LDL-C by 10% to 20% the most effective agent for increasing HDL-C lowers triglycerides by 20% to 35% at typical doses of 1.5 to 3 grams/day. can be used in combination with statins, and a fixed-dose combination of lovastatin and long-acting niacin is available

Mechanism of action

At gram doses, niacin strongly inhibits lipolysis in adipose tissue, thereby reducing production of free fatty acids (Figure 23.8). The liver normally uses circulating free fatty acids as a major precursor for triglyceride synthesis. Reduced liver triglyceride levels decrease hepatic VLDL production, which in turn reduces LDL-C plasma concentrations.

Pharmacokinetics:

Niacin is administered orally.It is converted in the body to nicotinamide, which is incorporated into the cofactor nicotinamide adenine dinucleotide (NAD+). Niacin, its nicotinamide derivative, and other metabolites are excreted in the urine. [Note: Nicotinamide alone does not decrease plasma lipid levels.]

Adverse effects:

Cutaneous flush (accompanied by an uncomfortable feeling of warmth) and pruritus.

Administration of aspirin prior to taking niacin decreases the flush, which is prostaglandin mediated.

Nausea and abdominal pain. Slow titration of the dosage or usage of the sustained-release formulation of niacin reduces bothersome initial adverse effects.

Niacin inhibits tubular secretion of uric acid and, thus, predisposes to hyperuricemia and gout. Impaired glucose tolerance and hepatotoxicity have also been reported.

FIBRATES

Fenofibrate, gemfibrozil are derivatives of fibric acid that lower serum triglycerides and increase HDL levels.

Fenofibrate is more effective than gemfibrozil in lowering triglyceride levels. Fibrates also increase the level of HDL cholesterol by increasing the expression of apo AI and apo AII.

FIBRATES

Therapeutic usesThe fibrates are used in the treatment of hypertriglyceridemias. They are particularly useful in treating type III hyperlipidemia

(dysbetalipoproteinemia), in which intermediate- density lipoprotein particles accumulate.

FIBRATES

Pharmacokinetics

Gemfibrozil and fenofibrate are completely absorbed after oral administration and distribute widely, bound to albumin. Fenofibrate is a prodrug, which is converted to the active moiety fenofibric acid.

Both drugs undergo extensive biotransformation and are excreted in the urine as glucuronide conjugates.

FIBRATES

Adverse effects: The most common adverse effects are mild gastrointestinal (GI) disturbances.

These drugs increase biliary cholesterol excretion, there is a predisposition to form gallstones.

Myositis (inflammation of a voluntary muscle) can occur, and muscle weakness or tenderness should be evaluated. Patients with renal insufficiency may be at risk.

Myopathy and rhabdomyolysis have been reported in patients taking gemfibrozil and statins together.

The use of gemfibrozil is contraindicated with simvastatin. Both fibrates may increase the effects of warfarin. INR should, therefore, be monitored more frequently when a patient is taking both drugs.

Fibrates should not be used in patients with severe hepatic or renal dysfunction or in patients with preexisting gallbladder disease.

Bile acid–binding resins

Benefits are less than those observed with statins. Cholestyramine,colestipol, and colesevelam are anion-exchange resins that bind negatively charged bile acids and bile salts in the small intestine The resin/bile acid complex is excreted in the feces, thus lowering the bile acid concentration. This causes hepatocytes to increase conversion of cholesterol to bile acidsConsequently, intracellular cholesterol concentrations decrease, which activates an increased hepatic uptake of cholesterol- containing LDL particles, leading to a fall in plasma LDL-C.

Bile acid–binding resins

Therapeutic uses: The bile acid–binding resins are useful (often in combination with diet or niacin) for treating type IIA and type IIB hyperlipidemias.

Cholestyramine can also relieve pruritus caused by accumulation of bile acids in patients with biliary stasis.

Colesevelam is also indicated for type 2 diabetes due to its glucose-lowering effects.

Pharmacokinetics: Bile acid sequestrants are insoluble in water and have large molecular weights.

After oral administration, they are neither absorbed nor metabolically altered by the intestine. Instead, they are totally excreted in feces.

Bile acid–binding resins

Adverse effects:

The most common side effects are GI disturbances, such as constipation, nausea, and flatulence.

Colesevelam has fewer GI side effects than other bile acid sequestrants.

These agents may impair the absorption of the fat-soluble vitamins (A, D, E, and K), and they interfere with the absorption of many drugs (for example, digoxin, warfarin, and thyroid hormone).

Therefore, other drugs should be taken at least 1 to 2 hours before, or 4 to 6 hours after, the bile acid–binding resins.

CHOLESTEROL ABSORPTION INHIBITOR

Ezetimibe • Selectively inhibits absorption of dietary and biliary cholesterol in the small intestine, leading to a decrease in

the delivery of intestinal cholesterol to the liver.

• This causes a reduction of hepatic cholesterol stores and an increase in clearance of cholesterol from the blood.

• Ezetimibe lowers LDL cholesterol by approximately 17%.

• Due its modest LDL-lowering effects, ezetimibe is often used as an adjunct to statin therapy or in statin-intolerant patients.

• Ezetimibe is primarily metabolized in the small intestine and liver via glucuronide conjugation, with subsequent biliary and renal excretion.

• Patients with moderate to severe hepatic insufficiency should not be treated with ezetimibe.

• Adverse effects are uncommon with use of ezetimibe.

OMEGA-3 FATTY ACID

Omega-3 polyunsaturated fatty acids (PUFAs) are essential fatty acids that are predominately used for triglyceride lowering.

Essential fatty acids inhibit VLDL and triglyceride synthesis in the liver.

The omega-3 PUFAs eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are found in marine sources such as tuna, halibut, and salmon.

Approximately 4 g of marine-derived omega-3 PUFAs daily decreases serum triglyceride concentrations by 25% to 30%, with small increases in LDL-C and HDL-C.

Over-the-counter or prescription fish oil capsules (EPA/DHA) can be used for supplementation, as it is difficult to consume enough omega-3 PUFAs from dietary sources alone.

Omega-3 PUFAs can be considered as an adjunct to other lipid-lowering therapies for individuals with significantly elevated triglycerides (≥500 mg/dL)

A

COMBINATION DRUG THERAPY

The combination of an HMG CoA reductase inhibitor with a bile acidbinding agent has been shown to be very useful in lowering LDL-C levels.

Simvastatin and ezetimibe, as well as simvastatin and niacin, are currently available combined in one pill to treat elevated LDL choesterol.

However, more clinical information is needed to determine whether combination therapy produces better long-term benefits than the use of a high-dose statin.

Until this uncertainty is resolved, many experts recommend maximizing statin dosages and adding niacin or fibrates only in those with persistently elevated triglycerides (greater than 500 mg/dL) or those with low HDL cholesterol levels (less than 40 mg/dL). Combination drug therapy is not without risks. Liver and muscle toxicity occurs more frequently with lipid-lowering drug combinations.

thank you